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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable,Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> FBusiness Name (DBA) C G 1'TtgiriQc-,rinc Address__3r 1 Oakdale I�oaci�—I <br /> a Owner Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> a. Business Telephone No. 7,27-8 1 1 r; Emergency Telephone No. <br /> Contractor Licence No. _ <br /> Applicants Name (Print) `T (:nr!i i:,sl Title i'>: <br /> .. .4 r..t'tc,�' oate��—�€i-8� <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No,.oSUGhernical Toilets Stored <br /> 3. EhCOLATION T�jST _/ <br /> Rt'or R.C.E. Name Alelvye V/1 R.S. or R.C.E. No. 33D38 <br /> Test Location 2I S�, S. GSCy Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> a <br /> Owner Address <br /> ❑ SEPTIC TANK, ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL!TOILETS For July 1, -June 30, 19 <br /> Type Construction! Disposal Site _ <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 3a, 19 <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served ` <br /> 7. ❑ LAUNDRY For Jul)('1; June 30;19"' <br /> Sl±t: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Us6d/Amount/Mo. <br /> a <br /> Home owner orlieenaedagent's signatt,+ee-,! if:esthefott6wt,;r "tcerti'/'heiintheperformanceoftheworkforwhich.thispermitisissued,ishallnotemployartyperson <br /> in such manner as to becdrne subject to workniati s compenal�;on 1,.vs o'C u crraz <br /> Contractor's luring or sub-contracting cnr rs- f: i..Cow:ng: "I certify that in the performance of the work for which this permit is issued,i shall <br /> employ persons subject to workman's comNansaiion iavis o.Cmiiwnia:' <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances,'state law -Pei sand reguI ns he San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> 40 Fee Is Due: ❑ ANNUALLY C3 PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Jcly 1 &Received By <br /> i BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE ATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS r <br /> PRORATION _ <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER S (J <br /> R ry by f Date Receipt No. Permit No Issuance Date Mailed Delivered <br /> LICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />